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Call or text:
406-898-8508
Email:
cornerstone.threeforks@gmail.com
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Dental Information
Last name
*
First name
*
Birthday
*
Month
Day
Year
Reason for today’s visit
Date of last dental cleaning
Date of last dental x-rays
Do you have a specific dental problem? If so, please describe
Please check if you have had any of the following
Bad Breath
Food collection between teeth
Limited jaw motion
Bleeding gums
Grinding
Loose teeth
Braces/Aligners
Gum treatment
Painful jaw
Broken teeth/fillings
Headaches
Pain when biting/chewing
Clenching
Jaw locking
Oral surgery
Facial pain
Joint sounds (clicking/popping)
Sensitivity to hot/cold/sweets
Other
Are you happy with your smile?
Would you like to have whiter teeth?
Would you like to straighten your teeth?
Would you like to learn about options to replace missing teeth?
What additional services would you like to learn about? Please check all that apply
Clenching/grinding treatments
Improvement of facial fine lines/wrinkles
Repairing broken/fractured teeth
Correcting facial asymmetries (eyebrows, lips, etc.)
Replacing missing teeth/implants
Improving thin lips/lip lines
Straightening crowded teeth
Veneers
Teeth whitening
Smile design
Other
Signature
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